Home Care in Serbia-Montenegro

March 2005 Dr Kay Richmond & Mrs Céline Mias For The British Red Cross Society

1 CONTENTS

1. INTRODUCTION & BACKGROUND...... 3 2. DEMOGRAPHY ...... 4 3. ECONOMY...... 5 3.8. PRSP FOR SERBIA...... 6 3.9. PRSP MONTENEGRO...... 7 4. HEALTH & WELLBEING...... 8 5. HOME CARE PROGRAMME (HCP)...... 9 5.1. METHODOLOGY OF THE REVIEW ...... 9 5.2. PROGRAMME TO DATE ...... 9 5.3. MAXWELL CRITERIA ...... 14 5.4. SWOT ANALYSIS...... 20 6. CONCLUSIONS AND RECOMMENDATIONS...... 24 ANNEX 1 - PEOPLE INTERVIEWED ...... 27 ANNEX 2 - DOCUMENTS REVIEWED ...... 29 ANNEX 3 - OUTLINE PROGRAMME FOR 3 YEARS ...... 30 11. REFERENCES...... 33

Acknowledgements Sincere thanks to Paul Emes, Uros Smiljanic, Vesna Lujic and Alexandra Tmusic of the IFRC, Natasa Todorovic, Milutin Vracevic of RCS, Slobodan Kalezic and Dejan Bojanic of the RCM, the drivers, all branches who received us and all who offered warm hospitality in Serbia and Montenegro. Also thanks to Olga Dzhumaeva and Heidi Gilert of the BRCS and Catherine Hine and Paul Hinchliff at HAI for commissioning and organising our visit to Serbia-Montenegro.

2 1. Introduction & Background

1.1. This review of the Home Care Programme (HCP)1, through participatory assessment, was commissioned by the British Red Cross Society (BRCS) using a team of UK, Serbia and Montenegro Red Cross (SMRC), International Federation of Red Cross/Red Crescent (IFRC) and international experts. The aim was "to deepen the understanding of the current programme and context and to prepare a three-year work plan, outlining BRCS input and designed to expand the programme to 10-20 branches".

1.2. The overall goal of the HCP is to seek to "…improve the quality of life for vulnerable older people without family support networks by enabling them to remain in their homes with dignity and to avoid social isolation and exclusion through the provision of the home care service, social integration and raising awareness".

1.3. In order to set the service review in context it is necessary to review some of the background information specific to Serbia-Montenegro. This, in turn, must be set within the body of knowledge regarding long-term care. According to the WHO2 "…the search for effective long-term care policies is one of the most pressing challenges facing modern society. There is no single converging paradigm and countries are experimenting with a number of different approaches. There is a need for a focused effort to summarize the state of the art in planning long-term care policies so that all countries can plan and implement appropriate services as an integral part of their health and social systems." A review by Professor Betty Havens 3 in 1999 for the WHO states "Not surprisingly, the largest body of topical policy material is about care giving, by both informal care givers, usually family, and formal care givers, such as staff….The major themes that emerge from the literature are the durability of informal care givers and warnings that policy must support informal care givers and that, without adequate support, informal care givers may not be able to sustain the current levels of care being provided." It is for these reasons that this review and the actions arising from it are of great importance for the elderly people of Serbia-Montenegro who have no means of support other than the Red Cross.

1.4. The break-up of the former Yugoslavia in 1991 was followed by war in the newly independent neighbouring states (1991-5) and a conflict in Serbia’s southern province of Kosovo (1999). Serbia and Montenegro have been affected badly by the social and economic impact of the wars, with high levels of unemployment and the effects of UN economic sanctions between 1992 and 2000. The country remains in a state of economic, political and social transition. Although the economic malaise has steadied, modest growth has to date had little impact on the most vulnerable. The situation facing those at the bottom of the social ladder is worsening as factories and other state owned enterprises continue to restructure or close4.

1.5. Much of the information about Serbia and Montenegro includes Kosovo but the picture is not uniform. Indeed the three areas differ from each other in some important respects. Serbia is, generally, less poverty struck than Montenegro whilst Kosovo is in an uncertain position with much tension affecting the wellbeing of the population currently.

1.6. A new constitutional charter was signed in January 2003 for Serbia and Montenegro and a referendum is to be held on independence early in 2006. Until this occurs there will inevitably be some uncertainty about the future organisation of Red

3 Cross - there being the SMRC with separate republican organisations in both Serbia (RCS), and Montenegro (RCM), in addition. Added to this are the separate legal entities of each Red Cross branch in each Municipality.

1.7. New Red Cross Laws are being drafted in both Serbia and Montenegro at present. These seek to regularise the position of the Red Cross. Humanitarian aid is decreasing and there is a need to establish the future pattern of organisation and programming. The relationship as an auxiliary to government is also being redefined. The revised Red Cross Law is a key part of this process, together with related laws on lottery funding, first aid training for drivers and regulations about responsibility for the recruitment of blood donors. Much effort has been invested in drafting and advocating with government for these laws, which seek to define both the role and responsibilities of the Red Cross as well as its funding. Home Care will be included as a clear RC task in both laws, and may well attract direct or indirect government funding. In theory, this should mean that the RCS/RCM branches could receive local government funding for home care activities, but in practice this is not likely to happen, as local governments are too stretched financially.

1.8. A fiscal situation which disadvantages the Red Cross is that both income and donations are taxed making it less attractive for people to give through, for example, Give-as-you-earn schemes. In addition, the recent introduction of VAT has conferred exemption on the IFRC but not the national Red Cross Society.

1.9. Serbia and Montenegro are home to Europe's largest population of refugees4 and internally displaced people (207,000 refugees and 270,000 IDPs according to UNHCR’s report in May 2004). Although many have returned to Bosnia-Herzegovina and Croatia, a significant number of those who remain require assistance to integrate within the local community; many are elderly.

1.10. The capacity of the government to respond to the needs of the vulnerable is increasing but unfortunately, its capacity is not likely to keep pace with decreases in international humanitarian assistance. Sizeable numbers of vulnerable persons are likely to remain - particularly amongst the elderly who may be economically inactive, are ineligible for pensions and whose families have left to seek employment elsewhere within the Republic or in other countries.

1.11. The Poverty Reduction Strategies (PRSPs) developed and adopted by the Serbian and Montenegrin governments are beginning to address this issue. The positioning of the Red Cross as a partner in PRSP implementation will be important as it seeks to increase its help to vulnerable populations. The Red Cross Laws referred to above will play a key role in such developments.

1.12. This report concentrates on Serbia and Montenegro since the review of the Home Care Programme has been carried out in these two areas only. A separate Plan of Action for Kosovo in 2005 has been prepared by the IFRC. 2. Demography

2.1. Most data are available for Serbia plus Montenegro plus Kosovo and will be presented for this area unless stated otherwise.

2.2. The population is, according to the World Bank 5, expected to increase from

4 10,637,000 in 2000 to 10,715,000 in 2010.

2.3. The numbers of people falling in the age range 60+ years will increase from 899,000 to 928,000 for men and from 1,110,000 to 1,148, 000 for women; the proportions are expected to remain at 17% and 21% respectively, an average of 18.4%. The dependency ratio (which includes children and the elderly) is expected to decrease from 51.4% to 48.3% over the same period.

2.4. Census data for Serbia (20026) and Montenegro (20037) show populations of 7,498,001 and 672,656 respectively. The proportions of people aged 60+ years are 22.46%6 and 22.00%8 respectively. For the slightly older age group of 65+ years the proportion overall has increased from 9.8% to 18.1% between 1980 and 20029.

2.5. Life Expectancy9, as in most countries, is less for men than women and is given as 69.7 years and 74.9 years respectively (average 72.3 years) by WHO in 2002. Healthy Life Expectancy is given as 62.7 years and 64.9 years (average 63.8 years) meaning that men can expect 7 years of poor health and women 10 years (average 8.5 years). Overall life expectancy has improved by 3 years between 1980 and 2002 whilst survival to age 65 years is 73% for men and 83% for women. This ageing of the population structure is typical of western countries.

2.6. According to the WHO 10, the numbers of people requiring daily care, based on two severest Global Burden of Disease study disability categories, will increase from 193,900 to 206,100 people in Yugoslavia (SMK) between 2000 and 2010.

2.7. The proportion of refugees and IDPs in Montenegro is 6.1% and for Serbia is 6.4% of the total population. 3. Economy

3.1. The GDP has been rising in both Serbia and Montenegro and is forecast to reach 4-5% by 2006. Neither has sufficient income at present to ensure timely payments of benefits to those who qualify - the delay varying between 3 (urban) and 14 months (rural). Social protection policy and payments are controlled centrally at present although both governments are committed to decentralisation and greater involvement of the Municipalities.

3.2. There are Poverty Reduction Strategies (PRSP) for both Serbia11 and Montenegro12. There is an increasing emphasis and expenditure (in real terms and as a proportion of GDP) on social welfare programmes.

3.3. Both highlight regional differences:

3.4. The south-east is most deprived, followed by the west in Serbia;

3.5. The north is most deprived, followed by central and southern regions in Montenegro.

3.6. Those aged 65+ years are poorer than those aged less than 65 years with people with agricultural pensions and those without pensions faring the worst. Single person and two-person households and those where the head of the household is a pensioner fare badly.

5 3.7. The indigenous population fares better than Internally Displaced People (IDPs) and the refugees, in descending order. Rural poverty is greater than urban poverty. The improvement in economic levels has been slower to reach the poor sections of the population.

3.8. PRSP for Serbia

3.8.1. A poverty review carried out during the PRSP process in Serbia revealed that 10.6 % of the Serbian population lived below the poverty line (

3.8.2. The population most at risk of poverty include:

· Elderly people (65+ years) and children;

· Elderly single-person and two-member households, particularly in rural areas;

· Agricultural pensioners;

· IDPs and refugees, as well as persons with disabilities.

3.8.3. Basic guidelines in the reform process of social services cover the de- institutionalisation and development of open (i.e. alternative) forms of protection aimed at putting the user and his/her needs at the centre. These include:

· Decentralisation;

· Abolishing discrimination which exists for particular categories of users;

· Development of professional standards, procedures, protocols and norms;

· Establishing partnership between governmental and non-governmental sectors;

· Creating an environment for the involvement of the private sector;

· Introducing permanent education principles for service providers (continuing professional development, CPD).

3.8.4. Poverty amongst people aged 65+ years varies by region as seen in Table 1. 3.8.5. This shows, perhaps surprisingly, that people without pensions in Belgrade and Vojvodina are poorer than those in western Serbia whereas those with pensions fare worst in the more expected areas of the east and west; people in south-east Serbia come out worst on all parameters. It may, however, be a consequence of crediting people owning land with greater resources even though they cannot benefit from it - through infirmity, for example. 3.8.6. The goals of the PRSP include strengthening of the non-institutional and service protection of particularly vulnerable elderly people.

3.8.7. In 2001 the average retirement age was 58 years. This has now been raised to 60 years - with the intention of it rising to 65 years in due course.

6 Table 1 - Poverty levels amongst people aged 65+ years 11

3.8.8. The main aim of help for the elderly population is directed at assistance to remain, with dignity, in their own homes through:

· Day centres, which offer support to elderly citizens while the members of their families work,

· Day rehabilitation centres, where the help is provided to those who were released from hospital, but who need improvement in functional abilities;

· Personal help at home, which includes feeding, personal hygiene, washing clothes;

· Cleaning the house, provision of transport;

· Medical help at home, intended for ill elderly people.

3.9. PRSP Montenegro

3.9.1. The PRSP for Montenegro commits to a national programme on social protection of the elderly, which would be in compliance with regional, municipal and local action programmes.

3.9.2. This would be based on principles which include:

· Decentralisation of the functions, responsibilities, funding and social and child protection practices;

· Promotion of partnership and networking between the different actors engaged in programmes and initiatives, especially at municipal and local level.

· The retirement age has been raised from 60 to 65 years for men and from 55 to 60 years for women.

3.9.3. The main objectives of the PRSP, relevant to the elderly include poverty reduction among retired and other old persons, and the strengthening of out-of- institution service delivery. These will be developed through:

· Facilities for caring for mentally disordered elderly (both refugees and domestic population);

· Day care centres for the elderly;

· Day rehabilitation centres;

7 · Teams providing home care.

3.9.4. The PRSP was developed through the participation of the Civil Society Advisory Committee, of which the Red Cross was a member. 4. Health & Wellbeing

4.1. The major causes of death are Cardiovascular Diseases and Cancers - as in all western countries. In Montenegro12 these are 53% and 17% of total mortality respectively.

4.2. The PRSP for Montenegro states " Access to healthcare in Montenegro is quite satisfactory. However, although existing capacities are adequately maintained, due to changing socio-economic standards, a reduction in the quality of health services is evident, which has lead to an increase in the utilisation of private sector services as well as increasing levels of corruption and use of bribery in the public sector." This makes access for the poor elderly particularly problematic. One of its main goals is "Improved quality of healthcare, especially for vulnerable groups, which must include equitable access.

4.3. Of importance to the Red Cross is the statement that "Experiences in Montenegro and the region show that NGOs have an important role in planning and implementing programs for vulnerable groups thus compensating for the social inequalities present in the health system. NGOs often have programs that are adjusted to the needs of specific marginal groups and have greater access to vulnerable communities, and can therefore play an important role in attitudinal change in terms of healthcare."

4.4. The prevalence of chronic disease in Serbia is 30.3% in people below the poverty line and 26.6% for those above11. The PRSP also notes that socially disadvantaged persons frequently receive health care services of poorer quality than the rest of the population.

4.5. A priority task for local communities is improved access to social, health care, educational and cultural services.

8 5. Home Care Programme (HCP)

5.1. Methodology of the review

5.1.1. The methodology used in the assessment included a review of documents relevant to the programme (Annex 2), interviews with key staff members, government representatives and other NGOs involved in older people’s programmes, and visits to 9 sites (only 8 visited by HAI consultant), involving group interviews with representatives from 20 branches (17 for HAI consultant), volunteers and beneficiaries. Thus information was gathered from 20.8% of participating branches.

5.1.2. Interviews and group interviews were conducted using participatory approaches as much as possible, including open questions and opportunities for volunteers and beneficiaries to express their views. The sites visited reflected a range of contexts, involving branches with varying capacities, diverse socio-economic situations, different levels of implementation and lengths of time involved in the programme, as well as both urban and rural environments.

5.1.3. All visits and interviews discussed in this report were made by a team composed of Kay Richmond (team leader), Céline Mias (HAI representative), a representative of the IFRC (either Uros Smiljanic or Vesna Lujic) and a representative of the RCS (Natasa Todorovic or Milutin Vracevic). In Montenegro the RCM HCP coordinator, Dejan Bojanic, accompanied the team.

5.1.4. Key findings of the assessment were presented and discussed with all relevant stakeholders at the end of the assessment visit to encourage their participation in decisions and plans being made for the future. Participants in this meeting included representatives from each site visited and key people interviewed. Unfortunately, the HAI representative was not present at this meeting, but contributed to its design and preparation before her departure from Serbia and Montenegro.

5.1.5. The following sections describe the results across the 20.8% of the participating branches reviewed, set against the demographic and economic background across both Serbia and Montenegro. However, given the inclusion of people aged less than 65 years in many branches and the availability of population data for the age group 60+ years from the censuses this age group has been used to make some of the statistical analyses. A further refinement has been to use 20% of this population (those at risk) for the calculations of coverage and equity. It is sufficiently accurate for the comparative purposes of this review but not for service monitoring. We would recommend therefore that the newly developed data base (which we have not been able to review) collects information in age bands which do allow accurate, complete and timely data collection - perhaps 60-64, 65-74 and 75+ years would be appropriate.

5.2. Programme to date

5.2.1. Home Care for the Elderly was a traditional service13, as part of the Social Welfare Programme (SWP), for many years prior to the years of conflict. It began with trauma centres in 11 regions in about 1993 and by 1999, 91 branches were involved. During the years of conflict much effort was directed at relief operations but the current political and economic situations dictate a move towards development and away from relief. During this transitional period it will be extremely important for the Red Cross to be flexible so that it can take maximum advantage of the opportunities which will

9 present themselves. The offer of support from the BRCS for the next three years will need to be used judiciously so that the programmes become sustainable when international humanitarian funds are available no longer.

5.2.2. The current HCP in the SMRC began as a pilot project in the Vojvodina region of Serbia in the latter part of 200014 and has developed to cover 96 branches nation-wide (84 branches in Serbia and 12 branches in Montenegro).

5.2.3. Inclusion criteria are people:

· Aged over 65 years of age - however a number of branches interviewed include people younger than this because their particular circumstances (e.g. physical disability) place them in the same need group as older people;

· Who have no or very low income;

· Who live alone or with someone else requiring assistance;

· Who are unable to perform daily activities on their own;

· Who are not in receipt of any similar assistance from another organisation.

5.2.4. The sorts of services provided include:

· Gardening;

· Light cleaning/tidying;

· Accompanying on walks (especially the blind);

· Fetching food from the soup kitchen or water;

· Shopping;

· Reading aloud/piano playing.

5.2.5. There are three funding models currently - based on the numbers of beneficiaries within the programme:

· Model 1 - up to 100 beneficiaries;

· Model 2 - 101 to 200 beneficiaries;

· Model 3 - 201 and over beneficiaries. 5.2.6. Key achievements of the whole project have been the recruitment and training of the volunteers, the implementation of community-based home care services, and the development of increasing linkages and collaboration with local authorities and communities. 5.2.7. The numbers of beneficiaries in the programme have risen to around 9,000 in Serbia and 900 in Montenegro during the last three years from 6432 and 810 in 2002 respectively.

10 Table 2 - HCP across the regions.

REGION MODEL 1 % MODEL 2 % MODEL 3 % TOTAL MUNICI- % MUNICI- WITH WITH WITH IN HCP PALITIES PALITIES HCP 1 HCP 2 HCP 3 WITH HC

Vojvodina 12 46.2 11 42.3 3 11.5 26 45 57.8

Central 14 53.8 8 30.8 4 15.4 26 54 48.1

South East 9 64.3 4 28.6 1 7.1 14 25 56.0

South West 12 66.7 5 27.8 1 5.6 18 36 50.0

Montenegro 9 75.0 3 25.0 0 0.0 12 21 57.1

Total 56 58.3 31 32.3 9 9.4 96 181 53.0

5.2.8. Table 2 shows the current distribution by region and funding level. It shows the south-east and south-west regions of Serbia and Montenegro to have the highest numbers of level 1 programmes and the lowest of level 3 (Montenegro has none) despite being the more impoverished areas. However, when looking at the 65+ years age group Vojvodina and central Serbia have the highest proportion of poor people amongst those without a pension - see Table 1.

5.2.9. The level of funding for each model was reduced this year in order to try and stimulate efforts to raise funds locally and through sources other than the IFRC. This has led to some branches commenting that the numbers of beneficiaries and of volunteers have fallen. Specific examples comparing 200315 with 2005 are in Table 3, which shows a mixed picture of changes between beneficiaries and the volunteers serving them:

· Kovin where we were told that the number of beneficiaries had fallen from 158 to 140 but volunteers appear to have increased from 57 to 80;

· Pancevo where the numbers of beneficiaries had fallen from 286 to 115 (in effect a drop from level 3 to level 2) and volunteers from 66 to 45;

· Sabac 443 beneficiaries to 300 and 32 to 20 volunteers;

· Velika Plana from 222 to 186 beneficiaries (a drop from level 3 to 2) but with an increase in volunteers from 9 to 12.

5.2.10. However, we noted that some branches had managed to increase the numbers of beneficiaries between 2003 and 2005, namely:

· Arandjelovac from 144 to 153 whilst sustaining a drop in volunteer numbers;

· Kagujevac from 287 to 300 with the same number of volunteers;

· Novi Beograd from 195 to 250 with a fall from 56 to 42 volunteers;

· Valjevo from 243 to 300 with an increase in volunteers from 18 to 19.

11 Table 3 - Numbers of Beneficiaries cf 2003 and 2005.

MUNICIPALITIES BENEFICIARIES VOLUNTEERS

2003 2005 2003 2005

Kovin 158 140 57 80

Pancevo 286 115 66 45

Sabac 443 300 32 20

Velika Plana 222 186 9 12

Arandjelovac 144 153 10 8

Kagujevac 287 300 42 42

Novi Beograd 195 250 56 42

Valjevo 243 300 18 19

5.2.11. These figures call into question the efficiency and effectiveness of branches and require further exploration. For now, it would seem that the changes in funding levels have had unexpected consequences.

5.2.8. In the past year (2004), the achievements of the HCP have included4:

· Delivery to an average (mean) of 8625 vulnerable beneficiaries16 each month (range 8082-9286, a mediana of 8661, NB - not all branches report each monthb) by an average of 1734 trained volunteers (range 1396-1830, median 1772) and an average of 152 paid professionals (range 147-159, median 152);

· Production and distribution of a reference and training manual to all implementing branches;

· Development, manufacturing and distribution of a record-keeping and reporting software package to all implementing branches;

· The fourth cycle of training for volunteers and professionals in the programme;

· Founding of the inter-agency advocacy network of organisations providing home care services as a coordination and lobbying body;

· Increased local government support to the HCP and increased sustainability of the programme in a number of branches.

5.2.9. The staffing of the programme in each branch includes community volunteers (in a The median is the middle value - 50th centile. b The SMRC gives the number of beneficiaries in 2004 as 8625 in Serbia and 910 in Montenegro, a total of 9535; the difference between these figures is probably due to the failure to submit figures each month by some branches, for the IFRC report.

12 Serbia, mostly over 50 year olds and some youth and military service volunteers, and in Montenegro, primarily youth), professional volunteers (doctors and nurses), and paid home care coordinators. Branch secretaries also support the programme, and some branches also pay salaries to health professionals who contribute their services. Staffing varies from branch to branch, with some branches run primarily by volunteers, and others relying more on paid staff. Larger branches have numerous sub-branches in each municipality and village in which they work. These sub-branches are managed by volunteer Red Cross ‘activists.’ The numbers of paid staff (recorded16) varied between 147 and 159 (median of 152) during 2004.

5.2.10. Volunteers receive training in basic skills involved in home care, including listening and communicating with older people and (in some branches) first aid and home nursing. Training is ongoing, with each training course building on skills developed in previous courses. In 2004, a training manual was produced and distributed to all implementing branches to serve as a reference document for home care coordinators and volunteers.

5.2.11. In Serbia, monitoring of the programme is led by branch HCP coordinators, and overseen by 4 regional home care coordinators. Each branch HCP coordinator visits each beneficiary about once per month and regional home care coordinators visit each branch every 3-4 months to discuss the programme with branch secretaries and home care coordinators, and make at least 2 random visits to beneficiaries. In Montenegro, monitoring of the programme is led by the RCM home care coordinator, who visits each branch every two months.

5.2.12. Each branch must submit a standard monthly report to the RCS and RCM in Belgrade and Podgorica respectively, including statistics on numbers of beneficiaries visited, numbers of volunteers involved, numbers of people assessed and on waiting lists, etc. An electronic database for the collection and analysis of such information has been developed recently, and its use is being phased in over the course of the coming year.

5.2.13. Volunteers are required to keep detailed accounts of the visits they make and services they provide. Documentation of their visits is submitted to the branch home care coordinators monthly, enabling them to compile their monthly reports. Volunteers in many branches also meet as a group once per month to exchange experiences, discuss any problems they may have had over the course of the month and suggest improvements for the future of the programme.

5.2.14. In 2004, the programme began developing advocacy activities at local and national levels (in Serbia). At local level, some branches have been increasing contacts with local authorities with the aim of obtaining funding agreements to ensure the sustainability of their programme. At national level in Serbia, the RCS founded a national advocacy network (the Elderly Advocacy Network) jointly with 15 other NGOs working on older people’s programmes in order to influence national decision-making processes affecting older people.

5.2.15. In another attempt to address the issue of sustainability, the RCS, with the IFRC and the Spanish Red Cross, is hoping to develop 'commercial' home care services (in future called income generating services) in Serbian branches, in parallel with the free community home care services they provide. These would, it is hoped, generate income which would allow the voluntary services to continue operating in future. What exactly

13 these services would entail is yet to be determined via a feasibility study, planned for April-May 2005. Following the study, a pilot phase of commercial services will be implemented in 7 branches, to ensure their suitability for wider implementation throughout the country. In addition, a number of RCS and RCM branches have already begun developing other income generation activities, such as laundry services, hairdressing, and rental of Red Cross facilities in order to obtain income to support their regular activities, including home care.

5.2.16. In Montenegro, the RCM has been asked to join a one-year pilot project by the National Employment Agency, funded by the World Bank, to provide employed nurses with work in home care. The RCM will supply its home care beneficiary lists and provide some free training to the project. Whilst it is recognised by the RCM that the scheme does not benefit the Red Cross directly, the partnership with government is viewed as an opportunity for the RCM to strengthen its position in negotiations over the Red Cross Law and other future funding agreements.

5.2.17. The HCP has been supported over the years by the Spanish Red Cross Society, the Canadian Red Cross Society, and the IFRC, which received some funding for the programme from the BRCS through its annual appeals. A number of external evaluations of the programme have taken place in the past, including an evaluation of the pilot programme in Vojvodina carried out by the Canadian Red Cross Society in May 200114 and an evaluation of the current programme in Serbia undertaken by the Spanish Red Cross Society in June 200315.

5.2.18. There are, however, a number of areas which need attention in order to develop a high quality programme which delivers on the basis of the assessed levels of need.

5.2.19. In order to assess the quality of the programme it will be discussed in terms of the Maxwell Criteria 17,18 which were developed originally to measure the quality of health care services.

5.3.Maxwell Criteria 5.3.1. Maxwell described six dimensions: 5.3.1.1. Effectiveness - having an intended or expected effect; 5.3.1.2. Efficiency - the ratio of the effective or useful output to the total input in any system; 5.3.1.3. Equity - the state, quality, or ideal of being just, impartial, and fair with resources being allocated on the basis of demonstrated need; 5.3.1.4. Accessibility - obtained easily; 5.3.1.5. Acceptability - adequate to satisfy a need, requirement, or standard; satisfactory; 5.3.1.6. Relevance - applicability to identified needs/wants; 5.3.1.7. A seventh dimension can also be considered, responsiveness - the ability to react appropriately to expressed/demonstrated needs/wants. 5.3.2. It has become customary to talk about needs and wants in assessing services - someone may want a particular service (e.g. an ambulance to get to a clinic) but they may not need it (e.g. a mobile person could use public transport or a taxi whereas a physically compromised person may need an ambulance). This distinction becomes crucial when using scarce resources and in assessing efficiency.

5.3.3. Effectiveness - The programme is effective in reaching many people in the target

14 group when only numbers are considered. About 9000 beneficiaries were included in the programme during 2004. However, taken as a proportion (20%) of the elderly (aged 60+ years, at risk) in the Serbian branches covered by the review, an average of only 5.4% (range 2.3% in Pancevo to 10.6% Mionica) of the people potentially requiring this service are included (Figure 1). Organisations other than Red Cross may also be delivering similar services in some areas and this needs to be taken into consideration when assessing the coverage of the service in each municipality. Also, in Montenegro there is an attempt at providing a state-funded service through the auspices of funding from the World Bank - see above. Figure 1 - Beneficiaries at risk/Population aged 60+ years %

12.0 10.0 8.0

% 6.0 4.0 2.0 0.0

Bar Kovin Niksic SabacTopola Alibunar LoznicaMionica Pancevo Valjevo Jagodina Podgorica VladimirciVozdovac Danilovgrad Kragujevac Velika Plana Arandjelovac Herceg Novi Novi Beograd

5.3.3.1. The effectiveness of individual service components cannot be assessed currently but development of qualitative analysis involving the beneficiaries would help to address this deficiency.

5.3.3.2. The effectiveness of recruitment and retention policies varies across both Serbia and Montenegro with the average proportion of the population involved with Red Cross being 0.03% (range 0.004% in Podgorica to 0.22% in Kovin.)

5.3.3.3. Five branches had been successful in obtaining 11 'social conscience' soldiers (conscientious obkecctors) - one branch had four. These were added to the volunteers in further analyses even though one was medically qualified and could have provided professional services. Others came from non-medical professions.

5.3.3.4. The services of 39 medical professionals had been recruited in 9 branches - 16 in Bar. 5.3.4. Efficiency - We were given figures which demonstrated that volunteers visited an average of 6 beneficiaries (range 2 (Niksic and Kovin) to 25 (Mionica) - Figure 2. This could be a misleading rate given the variability between urban and rural municipalities, varying geography and the varying difficulties in transport. Pancevo pointed out that some of their transport problems had been resolved by the provision of bicycles - eminently suitable in a flat landscape. 5.3.4.1.Data for 200416 across all the branches which reported showed that volunteers, on average, visited each beneficiary 2.7 times per month (range 2.5-2.9), making 13.5 (11.6-16.8) visits each. This seems reasonable given the universal opinion that the greatest benefit from the visits was the social contact afforded to the beneficiaries. This is not to deny the essential nature of the practical tasks performed. 5.3.4.1.

15 Figure 2 - Beneficiaries per Volnteer/Soldier.

30 25 20

% 15 10 5 0

Bar Kovin Niksic SabacTopola Alibunar Jagodina LoznicaMionica Pancevo Valjevo Podgorica VladimirciVozdovac Danilovgrad Kragujevac Velika Plana Arandjelovac Herceg Novi Novi Beograd

5.3.4.2.Data collected during our visits showed that each professional, on average, visited 76 beneficiaries (range 5 in Bar and 140 in Loznica). Clearly the frequency of visits also varied and it was impossible to assess the necessity of the visits.

5.3.4.3.During 200416 professionals made an average of 0.8 visits per beneficiary per month (range 0.7-0.9) making 45.6 visits each (range 39.4 to 50.3).

5.3.4.4.We were told that many of these visits were to take BP readings and blood sugar levels. There may be room for efficiencies here, depending on, for example, the need to check BP levels for people stabilised on medication since the available evidence worldwide is that checks no more often that 3-monthly, and as infrequently as 6 monthly, are justified19. This will bear further examination as the programme efficiency is examined in the future. Diminution in the frequency of visits to any one individual would create the potential for greater coverage. Clearly this principle may well apply elsewhere in the programme.

5.3.4.5.. The budget was significantly underspent in both 2003 (16.6%) and 2004 (14.9%) despite a drop in the allocated budget of 111,228CHF, with a drop in beneficiaries served of 1142 (11.7%) in Serbia and 10 (1.1%) in Montenegro (Table 4). The budget for 2005 (unconfirmed) has increased by 34,702CHF. The numbers of beneficiaries included during the first quarter of 2005 have increased by 455 (5.3%) in Serbia and remained the same in Montenegro.

5.3.4.6. Expenditure rose by 209,833CHF (47.4%) between 2002 and 2003 and fell by 86,782CHF (13.3%) between 2003 and 2004.

5.3.4.7.These variations have given rise to fluctuations in the budgetary allocation per beneficiary from 71.18CHF in 2002 to 68.12CHF in 2004 and to 68.49CHF in 2005. Despite this there have been falls in expenditure per beneficiary from 61.09CHF in 2002 to 59.30CHF in 2004; an improvement in the cost:efficiency of the programme overall, provided that the services provided have been similar but we have no way of judging this.

16 Table 4 - Income and expenditure 2002-2005.

YEAR APPROVED ACTUAL BvA BUDGET EXPENDITURE BUDEGT per COST per BUDGET EXPENDITURE INCREEASE INCREASE BENEFICIARY BENEFICIARY 2002 n/a 442416 #VALUE! 61.09 2003 760726 652249 -108477 +209833 71.18 61.03 2004 649498 565467 -84031 -111228 -86782 68.12 59.30 Jan-Mar 684200 n/a +34702 68.49 2005 NB - the currency is CHF

- BvA = Budget versus (CF) Actual

5.3.5. Equity - Much of the data above pays no regard to the equity of service provision. Those areas which are poorest seem to be receiving similar or lower levels of service than those with greater material resources (Table 3 and Figure 3).

5.3.5.1.We have seen above that the greatest poverty is experienced in south-east and south-west Serbia and in northern Montenegro. However, there is some evidence that Vojvodina and Belgrade have the greatest levels of poverty amongst the elderly population11 who do not receive pensions. This might be due the assessment of rural people owning land as being wealthier than those who do not despite their inability to make use of it due to decreasing physical abilities. There is also the discrepancy between the coverage of populations by the pension system with more in the agricultural communities failing to qualify and thus being lost to the more formal data collection systems. This conundrum requires further elucidation - qualitative studies may help here as would more complete cost:benefit analyses.

5.3.6. Accessibility - According to anecdotal evidence gathered during this assessment, significant numbers of older people are living in isolated conditions in rural areas and villages, having been left behind by younger generations seeking work in cities or abroad. Many of these older people have no access to medical services or transport, and have little recourse to assistance. One case mentioned was of an older woman who has to walk 5km just to reach the nearest road, but this seems to be a fairly common situation in rural areas in both Serbia and Montenegro. The need of rural inhabitants for neighbourhood assistance/home visits and linkages with wider support networks is therefore significant. While working in rural areas tends to be less cost:efficient (higher cost per beneficiary) than working in urban areas, expansion to these areas should still be prioritised, given the extreme vulnerability and isolation of their inhabitants. Unfortunately, many branches which could work in these areas are unable to do so due to prohibitive fuel/transport costs, though a few in Serbia have been successful in negotiating with local governments to provide some assistance with transport/fuel to cover these areas and, in Pancevo/Kovin/Alibunar to the acquisition of bicycles.

5.3.6.1.Some beneficiaries also access RCS soup kitchens. Not all branches have soup kitchens, neither do branches in Montenegro. Branches which run soup kitchens bid ten years ago to run them and received equipment and training for this purpose. Currently, soup kitchens receive government support. It would be difficult for branches with no soup kitchens to develop this activity, due to lack of equipment and capacity, withou capital investment. It is assumed that there is a need to develop them where they do not exist, though this has not been assessed.

5.3.7. Acceptability - Most branches described discussing the needs of each beneficiary

17 with them, and their families where relevant, in order to be sure that the need was perceived by both giver and receiver and the services to be provided were agreed.

5.3.7.1.Some older people were very hesitant to accept a young volunteer into their home and it could take a long time to gain the trust of beneficiaries. This is in part because some older people have been victims of scams by organisations offering home visit services in exchange for their flats. But the Red Cross reputation and symbols have helped beneficiaries and their families overcome their fears. 5.3.7.2.It might be that acceptability would increase if beneficiaries themselves are encouraged to offer help to others - for example, passing on skills such as handicrafts and in making items for sale as an income generation project - this is happening in Kragujevac. It would also help to increase beneficiaries' sense of worth and wellbeing and participation in their communities. 5.3.8. Relevance - The programme is particularly relevant in that it targets older people, who are identified in the PRSPs, as one of the most vulnerable groups in society. Indeed, both the numbers of older people in Serbia and Montenegro and their care needs are increasing, as younger generations and family members continue to move away from their towns and villages to urban areas or abroad in search of employment, leaving older people living alone and isolated, in need of care.

5.3.8.1.HCP is of fundamental importance and is generally successful in providing an appropriate and needed low-cost service to extremely vulnerable older people.

5.3.8.2.The nature of the programme itself is highly relevant for the Red Cross in Serbia and Montenegro, as it represents a traditional core activity.

5.3.9. Responsiveness - In order to retain viability any programme needs to change in response to changing circumstances. Organisational capacity is unequal among branches. Some branches appear to be competent or even fairly skilled in programme management and strategic planning, whilst others have few skills in this area. Currently, only the stronger branches are viewed as having the capacity to produce quality proposals, budgets and reports. Most of the weaker branches do not have much capacity in developing fundable proposals or funding strategies and risk the closure of their HCP when funding is no longer provided for them. The transition from relief to service provision is proving particularly problematic for some. Decreases in funding across the three models of service have had variable effects, as detailed above.

5.3.9.1.An important ingredient of responsiveness is flexibility. One of the weaker areas was the reliance of some branches on older volunteers with others relying on younger members only. Clearly older volunteers will become less able as they age and they may become beneficiaries themselves. Younger volunteers often move away to gain further education or to seek employment. A mix of age groups amongst volunteers would help to mitigate these effects.

18 Figure 3 - Map of the HCP municipalities

19 5.4. SWOT analysis

5.4.1. Strengths - The Red Cross has been established since the 1870s in Serbia and Montenegro and is well known for its services throughout previous and more recent conflicts.

5.4.1.1.Each local Red Cross branch is embedded in its local community so the wide geographical scope of the programme is manageable.

5.4.1.2.As has been reported in previous assessments, the strength of the HCP lies in its volunteers, without whom the programme would not exist.

5.4.1.3.The Red Cross is held in high regard by government, both national and local, and has been mentioned and involved in the PRSP developments.

5.4.1.4.The developing network with other NGOs and involvement in the Government Council for the Issues of Ageing and Old Age in Serbia, and the involvement with the Civil Society Advisory Committee and the National Employment Agency in Montenegro should help to build strong bridges with government and communities involved in improving the lot of the vulnerable elderly population.

5.4.1.5.The transition from relief to service delivery has started with development of Participatory Community Development (PCD), commercial First Aid and the current training packages. The IFRC has been developing an organisational development (OD) programme and tool kits to address the low capacity of many branches to develop quality funding proposals and bids, including training in project cycle management. The training has not yet been delivered, but materials currently being produced could be used to support the development of HCP branches in future.

5.4.1.6.Interlinking of the HCP with the Social Welfare Programme (SWP) should help to improve the services delivered. The SWP is undergoing review concurrently with this review of HCP - synergies should therefore be sought. Some branches also run soup kitchens (under the Disaster Management Programme) and older people’s clubs (as part of the HCP), and the HCP volunteers often assist beneficiaries in obtaining meals or other Red Cross services.

5.4.1.7.The recently introduced data collection system should help with monitoring the programme but without seeing the package it is difficult to advise on the need to modify the information being collected. Some of the information which could be available has been discussed above but this requires further assessment. It is imperative that the data collected are relevant, timely, complete and accurate if the full benefit is to be realised.

5.4.2. Weaknesses - The absence of a Red Cross Law is a distinct disadvantage but, as detailed above, it is hoped that this omission will be rectified soon.

5.4.2.1.The separate legal structures of the SMRC, RCS and RCM and their branches make performance as a cohesive body problematic. This increases the difficulties in moving towards standardised information gathering which in turn leads to a decreased ability to design projects likely to attract funding and weakens the strategic development required.

5.4.2.2.A key weakness in the programme is the low level of qualitative information being collected through monitoring and programme development processes. Currently,

20 most data being collected is statistical in nature, and does not give a good picture of the qualitative results of the programme and the underlying issues facing beneficiaries in their daily lives or volunteers in their work. There also appears to be a lack of rigorous information about the real needs of communities in which Red Cross branches operate. Information of use could include:

· An analysis of the home care needs of the population in each municipality or village covered, or potentially covered, by a Red Cross branch;

· The strengths and weaknesses of each branch’s programmes and geographical coverage;

· The needs of volunteers;

· The perspectives of the beneficiaries;

· The need for different types of services, clubs or income generation activities.

5.4.2.3.This situation can be attributed to the fact that the SMRC staff do not have sufficient training in gathering qualitative data in appropriate, participatory ways, and that it is much easier simply to collect figures from the volunteers and compile these into a brief monthly report. Most branches work in a fairly top-down manner; all programmes are designed centrally in Belgrade or Podgorica, or by branch secretaries and coordinators, and monitoring is undertaken by paid staff. In many cases, volunteers have little structured input in monitoring or the further development of the programme. While occasionally volunteer or beneficiary suggestions are taken on board by branch secretaries/coordinators, this occurs on an infrequent basis, if at all. In some branches interviewed, coordinators expressed the view that older volunteers and beneficiaries do not have the ability to input meaningfully into programme design and monitoring processes. Few of the branches had considered involving older people or volunteers in anything beyond actual home care service delivery or passive receipt of services. There are some notable exceptions where older volunteers serve as sub-branch coordinators, providing mentoring and advice for other volunteers in their municipalities.

5.4.2.4.Organisational capacity is unequal among branches. Some OD training was provided previously via a Geneva-based programme, but the course did not have much impact as it was considered too confusing for participants. This may in part be due to the fact that training on all issues related to assessment, proposal design and budgeting was delivered in a compact, 4-day training event - too short to cover such an array of complex topics. It may also be that the training modules were not appropriate to the knowledge and skills levels of the participants.

5.4.3. Opportunities - With the hoped for introduction of the Red Cross Law, and inclusion in both Serbia and Montenegro of the care of older people, there should be great opportunities for gaining contracts which could provide the necessary core funding for the HCP to continue and for it to develop in breadth, depth, quality and coverage. The intention to decentralise service commissioning and funding should also present greater opportunities, and Red Cross branches could begin now to develop closer linkages with local authorities in order to be well-placed to obtain funds when/if these are available. Most of the SMRC branches already have reasonably good relationships with local authorities, health centres and social welfare centres, as this was a prerequisite to joining the HCP. In some Serbian branches, funding relationships with local

21 government are already being built - most soup kitchens are at least partially supported, and some branches have already obtained support for their HCP activities. In most cases, these relationships can be built upon and exploited further through use of different profile-raising and lobbying techniques, including the active participation of older people and community-level awareness-raising.

5.4.3.1.The commitment of the BRCS to work hand in hand with the society in Serbia and Montenegro and the IFRC to develop HCP over a three year period presents a "not to be missed" opportunity to complete the transition from relief to service development. The BRCS delivers similar programmes throughout the UK and thus there could be opportunities to learn from such experience.

5.4.3.2.There are opportunities available within the Red Cross with regards to participatory methodologies. The RCS has been implementing participatory methodologies and has an in-house PCD trainer (who is also responsible for PCD in Montenegro) and support from the IFRC Regional Delegation in Budapest for this purpose. Some of the branches participating in the HCP have already been trained in PCD in relation to a different programme, and there are some (as yet undefined) plans to train branches specifically in relation to the HCP. RCS plans, therefore, would fit nicely with some of the recommendations made below. In addition, capacity exists to implement further PCD training.

5.4.3.3.The movement from PRSPs to action plans for implementation provide unparalleled opportunities to develop the HCP. The BRCS has expressed interest in extending it to include a further 10-20 branches. This is likely to be possible following the RPA suggested in this report. This does not seem overly ambitious but the need to address equity of provision and, perhaps the consequent greater OD assistance required for new and older participating branches which may not be particularly strong, together with the greater needs of the populations and for basic equipment might limit the number of new participating branches.

5.4.3.4.However, in addition to expansion, the three-year programme should look at deepening and consolidating the coverage of branches already involved. Most branches would like to move from levels (or ‘models’) 1-2 to level 3 of implementation, increasing the number of beneficiaries they reach over 200 people. Many branches interviewed through this assessment already have long waiting lists of older people wishing to be included in the programme. A number have also begun to develop older people’s clubs and day centres to provide further support to beneficiaries of the home care services.

5.4.3.5.An important area for expansion within existing branches is coverage of rural areas, which is insufficient currently (see Para 5.3.6).

5.4.4. Threats - The withdrawal of international humanitarian funds as the Serbian and Montenegrin Governments move towards decentralisation presents the Red Cross with a threat of less secure funding but also with the opportunity of developing self-sustainable programmes.

5.4.4.1.The Red Cross Law will only be of benefit in the form anticipated if the governments' revenues enable them to fund the services to which the PRSP commits them. There will be the need to obtain additional funding through income generation projects, and through attracting funds from sources such as the EAR-funded Social

22 Innovation Fund, and other international funds such as Embassy and World Bank grants.

5.4.4.2.The need to broaden the volunteer base has already been mentioned, failure to do so increasing the threat to the viability, not only of the HCP and SWP, but to the Red Cross movement itself. Balanced and viable recruitment and retention policies will need to be developed and implemented.

23 6. Conclusions and Recommendations

6.1. Findings from this assessment are very similar to findings from previous evaluations of the programme. No new discoveries were made and most recommendations will focus on developing areas which have been identified as weaknesses in the past.

6.2. The newly developed data base (which we have not been able to review) should collect information in age bands which do allow accurate, complete and timely data collection - perhaps 60-64, 65-74 and 75+ years would be appropriate. The data items need to be considered carefully so that only relevant information is collected - all too often items are collected simply because it is possible so to do. This is a waste of resources and does not improve management. Suggestions for these are contained in Annex 3.

6.3. The current funding mechanism makes no allowances for equity of provision. There is significant variability in this criterion as demonstrated above. This leads in turn to an unfair distribution of resources. Development of a weighted capitation formula should be undertaken but this will not be possible without the development of the information system.

6.4. Consideration should be given to funding transport costs in rural, more deprived areas (at least until other sources of income are found) and in recruiting more volunteers living in those areas, so that this inequity can be addressed.

6.5. Sustainability has been mentioned repeatedly as a key area of concern for most branches, as they are aware that external funding for the HCP will soon come to an end and that local solutions must be found. To this end, development of awareness-raising and lobbying activities and partnerships with local authorities and other NGOs through networking is crucial.

6.6. Given the lack of qualitative information available on the project sites and the lack of participatory methodology used in HCP design and monitoring, training in participatory research methodologies should be provided for local branch coordinators, volunteers and RCS and RCM staff, with specific emphasis on the participation of older people. Following the training, rapid participatory assessments20 (RPA) should be conducted in a selected number of actual and potential project branches in the first instance and then rolled out to others, in order to develop a baseline and a better qualitative and quantitative picture of the programmec. A participatory monitoring process should likewise be put in place in order to continue to collect relevant qualitative data and check baselines. Volunteer leaders and mentors can be trained to assist branch coordinators with qualitative monitoring processes.

6.7. Capacity building should include:

· Development and implementation of training modules on proposal development, budgeting, reporting, strategic planning and funding, based on existing IFRC training materials;

c RPA should triangulate data collected through qualitative and quantitative analysis in order to paint a more complete and comprehensive picture.

24 · Development and implementation of training modules in volunteer recruitment and retention;

· Production of a training manual/toolkit (adding to or building on previous toolkits developed by the IFRC).

6.8. More resources should be devoted to networking at local, Red Cross network and national levels, with the aim of instilling a genuine commitment to networking and information exchange within the SMRC, the Serbian Elderly Advocacy Network, and among NGOs in Montenegro, in order to improve the quality of programmes being delivered to older people and increase the profile and influence of older people’s organisations;

6.9. Branches should be encouraged to network and coordinate with other NGOs working in their area through bi-monthly coordination meetings:

6.9.1. At the level of the Red Cross branch network, quarterly regional branch meetings should be supported, a HCP newsletter should be produced (3-4 times per year, in simple format which can be both printed and sent via email) to highlight best practice in the network and exchange tips and information among different branches, also exchange visits should be introduced to allow branches to visit each other within the project period;

6.9.2. At national level in Serbia, monthly meetings of the Elderly Advocacy Network should continue and exchange visits among network NGOs should be supported in order to develop mutual understanding and an 'esprit de corps' and to promote information exchange. Depending on interest within the network, joint training courses on networking, strategic development of the network, and mentoring/advocacy/lobbying could be provided to them, to improve communication among network members. They could also produce action plans for future work. If network NGOs are interested, a policy newsletter could be produced 2-3 times per year to ensure that all of their branches and local partners are informed of network activities, best practice and policy achievements. Responsibility for production of the newsletter could be shared among network members, either through nominations for one NGO to coordinate the newsletter or through rotation for this responsibility for compilation of the newsletter.

6.9.3. In Montenegro, a national network should be encouraged and supported with monthly meetings, exchange visits and training to develop plans and mentoring/advocacy/lobbying capacity, as appropriate.

6.10. SMRC branches should be trained to develop local awareness-raising and lobbying campaigns, led by older people, to improve their standing within their local communities, raise awareness of older people’s issues, influence decision-making processes affecting older people, and increase potential for development of funding relationships with local authorities. Few branches rely on older people (volunteers or beneficiaries) to lead awareness-raising and lobbying activities, so this should be central to the training provided.

6.11. Investigation of income generation activities and, if feasible, support for these programmes should be developed - depending on the outcome of the pilot project. Services which could be explored include transport and escort and the provision of medical aids.

25 6.12. A novel way of funding activities - a time bank 21 - in which volunteers trade hours of service with beneficiaries, and perhaps other volunteers or local institutions, in order to gain new knowledge and skills is worthy of further exploration.

6.13. We commend an outline programme for the 3-year collaboration between BRCS, SMRC and the IFRC detailed in Annex 3.

26 Annex 1 - People interviewed

1. Interviews in Belgrade and Podgorica

1.1. 14 March 2005 - the HAI representative joined the last interview and attended all others until 24 March 2005:

· Paul Emes, Head of Delegatioon, IFRC, Belgrade;

· Uros Smiljanic and Vesna Lujic, Programme Coordinators, IFRC, Belgrade;

· Ljubomir Miladinovic, Head of Iinternational Relations Department and Ljiljana Gomilanovic, HCP Coordinator, SMRCS, Belgrade;

· Vesna Milenovic, Secretary, RCS, Belgrade;

· Natasa Todorovic and Milutin Vracevic, HCP Coordinators, RCS, Belgrade.

1.2. 15 March 2005:

· NGOs in Belgrade—University of the Third Age, Lastavica, Caritas--15 March 2005, Belgrade;

· Radmila Popovic, President of the Health Committee of the RCSM and RCS (home care trainer);

· Lidija Kozarcinin, Counsellor to the Minister of Labour, Employment and Social Policy, Belgrade;

· David Martin Ecudero, Head of Delegation, and Svetlana Radojevic, Programme Coordinator, Spanish Red Cross, Belgrade.

1.3. 21 March 2005:

· Slobodan Kalezic, RCM secretary, and Dejan Bojanic, RCM HCP coordinator, Gorica Bukelic, Podgorica;

· Snezna Mijuskovic, Deputy Minister, Ministry of Labour and Social Welfare, Podgorica.

1.4. 23 March 2005:

· Dragan Milosevic, PCD Coordinator RCS, SanjaPupacic, Regional PCD Coordinator, IFRC Central Europe Delegation in Budapest, Belgrade.

1.5. 24 March 2005:

· Srdan Mikovic, Vice President City Red Cross of Pancevo and Mayor, Pancevo;

· Suzana Jovanovic, Member of City Council, Panceveo.

2. Site Visits

2.1. Site Visit 1: Sabac Branch (including interviews with representatives from Valjevo, Loznica,

27 Mionica, and Vladimirci), 16 March 2005, Serbia;

2.2. Site Visit 2: Kragujevac Branch (including attendance of part of an Elderly Advocacy Network meeting), 17 March 2005, Serbia;

2.3. Site Visit 3: Arandjelovac Branch (including interviews with representatives from Jagodina, Topola and Velika Plana), 18 March 2005, Serbia;

2.4. Site Visit 4: Podgorica Branch (including interviews with representatives from Danilovgrad and Niksic), 21 March 2005, Montenegro;

2.5. Site Visit 5: Bar Branch, 22 March 2005, Montenegro;

2.6. Site Visit 6: Herceg Novi Branch, 22 March 2005, Montenegro;

2.7. Site Visit 7: Novi Beograd Branch, 23 March 2005, Serbia;

2.8. Site Visit 8: Vozdovac Branch, 23 March 2005, Serbia;

2.9. Site Visit 9: Pancevo Branch (including interviews with representatives from Kovin and Alibunar), 24 March 2005, Serbia;

2.10. End of Review workshop, Belgrade - 25 March 2005. Table 1 - Attendants at site visits. BRANCH SECRETARY COORDINATOR VOLUNTEER PROFESSIONAL CONSCIENTIOUS BENEFICIARIES OBJECTOR Alibunar 1 1 Arandjelovac 1 1 2 0 1 5 Bar 1 1 1 Danilovgrad 1 1 1 Herzeg Novi 1 3 Jagodina 1 1 1 0 0 0 Kovin 1 1 1 Kragujevac 1 1 1 0 0 0 Loznica 0 1 1 0 0 1 Mionica 0 1 0 0 1 0 Niksic 1 2 Novi Beograd 1 1 1 Pancevo 1 2 5 2 1 2 Podgorica 1 2 Sabac 0 1 4 2 2 3 Topola 0 1 0 0 1 1 Valjevo 0 1 2 0 0 1 Velika Plana 0 1 2 0 1 Vladimirci 0 1 1 1 0 0 Vozdovac 1 1 2 Total 9 19 32 5 6 15 A club for the elderly was visited in Kovin where 10 beneficiaries took part in a discussion about their circumstances and the help the RCS was giving them plus home visits were made to 2 beneficiaries in Kagujevac and one in Sabac.

28 Annex 2 - Documents reviewed

1. Allaire Sandra. 'Care of the Elderly' Conference - Vrnjacka Banja, 25-26th April 2001.

2. Allaire Sandra. Report on the Initiation of a Home Care Programme in the Federal Republic of Yugoslavia, by the Yugoslav Red Cross Society; Canadian Red Cross Society May 2001.

3. Home Care Programme, Framework; Yugoslav Red Cross Work Plan 2002.

4. Mears Catherine, Health Programme Adviser, British Red Cross Society. Visit to Serbia and Montenegro; 16-21st March 2003.

5. Escribano Catalina Alcaraz, Project Officer on Elderly People, Activities and Services Department, Spanish Red Cross Society. Evaluation of the Home Care Programme for Elderly People Living in Central Serbia and Voivodina; 26th May - 7th June 2003.

6. IFRC. Proposal Submission, Serbia and Montenegro Red Cross Society Home Care Programme; November 2003.

7. IFRC. Report of the Home Care Programme; 2004.

8. World Bank. Poverty Reduction Strategy Paper; February 2004 : .

9. IFRC. Serbia and Montenegro (including Kosovo); Appeal 2005.

10. IFRC. Plan of Action, Home Care 2005, RCK and RCKM.

29 Annex 3 - Outline Programme for 3 years 1. Goal 1.1. To improve the quality of life of elderly people through improving and extending the Home Care Programme (HCP) and ensuring its sustainability. 2. Objectives 2.1.Ensure participation of the beneficiaries, volunteers and paid staff in the design and running of the programme within 3 months of the start of the programme;

2.2.Develop participatory mentoring, advocacy and lobbying elements and guidelines for the recruitment/retention of volunteers within 6 months of the start of the programme;

2.3.Develop a range of services which meet the identified needs within each participating branch/community within 6 months of the start of the programme;

2.4.Ensure a relevant database and reporting system is in place within 6 months of the start of the programme;

2.5.Review the current pilot of income generation projects (commercialisation) by 31 December 2005 and roll out those projects which have proved of benefit;

2.6.Develop a timetable for implementation and reporting of the selected services in each participating branch within 12 months of the start of the programme;

2.7.Ensure sustainability of the programme beyond the 3-year period of support from the BRC. 3. Tasks 3.1.Undertake Rapid Participatory Appraisal (RPA) to include needs, vulnerability and capacity (combining qualitative and quantitative data) at the start of the programme, half way through and at the end of the programme;

3.2.Develop new services and income generation projects as indicated by the RPAs;

3.3.Review the current database and modify according to the services included and the indicators developed;

3.4.Agree the services to be delivered and a timetable for implementation of new projects with each participating branch;

3.5.Develop and implement appropriate training programmes in each participating branch covering:

· Modules available currently (e.g. project design, finance) for relevant personnel;

· Comprehensive coverage of some training for all paid staff and volunteers (e.g. communication, First Aid training - based on the IFRC Community Based FA development process - with regular refreshers and certification);

· Develop and deliver new training modules as appropriate - e.g. mentoring, advocacy,

30 lobbying, recruitment/retention of volunteers, strategic planning and funding;

3.6. Develop formal and regular mechanisms for sharing experiences between branches and regions - this could be through meetings, seminars, inter-branch visits and a newsletter;

3.7.Review current sources of funding for each participating branch and explore the possibilities of alternative and additional sources;

3.8.Secure funding beyond the end of the 3-year BRC programme. 4. Indicators 4.1.Resident population - broken down by age/sex, income bands, dependency measures - numbers and rates;

4.2.Programmes delivered currently with numbers and rates of beneficiaries covered;

4.3.Numbers of paid staff and volunteers in each branch - to include military personnel and professional people separately within each category - broken down by age/sex, skills, training undertaken, frequency of involvement, programme(s) in which involved, reasons for leaving;

4.4.Numbers, frequency and rates of visits undertaken by volunteer/staff member groups to the beneficiaries;

4.5.Numbers, frequency and rates of visits to centres/clubs by beneficiaries;

4.6.Costs of each programme overall, per branch and per beneficiary;

4.7.Sources of funding for each programme - total and per beneficiary by branch;

4.8.Training sessions attended by category of participant, frequency, branches involved and course evaluation;

4.9. Network meetings/visits organised, attendants, lessons learned reported and shared across the network on a quarterly basis by means of a newsletter. 5. Monitoring 5.1.Each report (data and commentary) to be compiled and sent to RCS, RCM, SMRC, BRCS and IFRC monthly;

5.2.Visits to each participating branch/region by the relevant programme coordinator from the RCS and RCM quarterly with reports to include strengths/weaknesses/opportunities/threats, implementation of previous actions agreed and the resultant agreed recommendations ;

5.3.Visits to each participating branch/region by the relevant programme coordinator from the IFRC and/or the BRCS six-monthly with reports similar in format to those recommended above and reviewing the branch and regional reports;

5.4.Annual seminar across Serbia-Montenegro for key personnel from each section of the programme;

31 5.5.By undertaking the baseline RPA assessment and one half way through the programme it should be possible to make any necessary adjustments for the second half - a further RPA at the end would then help in evaluating the success or otherwise of the entire 3-year programme and in making recommendations for the future. 6. Expected outcomes 6.1.Programmes which meet the Maxwell Criteria (efficient, effective, equitable, appropriate and acceptable, accessible, relevant and responsive);

6.2.New services developed and volunteers recruited and retained;

6.3.More branches involved across Serbia-Montenegro;

6.4.A higher proportion of those in need covered by the services within each branch, region and country;

6.5.A more equitable distribution of resources;

6.6.Greater involvement of beneficiaries and volunteers in the assessment, development and resourcing of programmes;

6.7.A higher level of core funding obtained from government (local and national) and other supplementary sources such as private employers, the EU and World Bank;

6.8.A higher level of funds raised locally - e.g. through income generating projects;

6.9.All these elements should help to ensure an improved quality of life for those most in need. 7. Evaluation 7.1.Using the regular reports, visits, seminars and RPAs outlined above it should be possible to track developments and improvements throughout the programme and to make any necessary adjustments timeously. 8. Finance 8.1.It is impossible to make detailed budget suggestions at this stage but consideration should be given to front-loading the investment in favour of programme support (e.g. equipment required to support development, not supplies) in order to allow the time required for conducting the needs assessments and development of the elements identified. This would evolve into a future diminution of programme materials with greater investment into the OD elements, climaxing in an improved service in quality, depth and breadth of individual elements, and sustainable, without further international NGO/Red Cross support, through national and local government funding, income generating projects and successful bids to agencies such as development banks/institutions.

32 11.References

1 Terms of Reference - Joint Assessment of Home Care programme in Serbia and Montenegro, between the British Red Cross Society & the Red Cross of Serbia and Montenegro; January 2005. 2 http://www.who.int/chronic_conditions/ltc/en/ - accessed 1 April 2005. 3 Havens Betty. Home Care Issues and Evidence, WHO/HSC/LTH/99/2, 1999. 4 IFRC. Appeal 2005; Serbia and Montenegro (including Kosovo). Appeal number 05AA065. 5 http://devdata.worldbank.org/hnpstats/dp.asp - accessed 31st March 2005. 6 www.statserb.sr.gov.yu/Pod/ePok.asp - accessed 31st March 2005. 7 www.geohive.com\/cd\/link.php?xml=cs&xsl=xs4 - accessed 31st March 2005. 8 http://www.ccmr-bg.org/javnost/public003.htm - accessed 31st March 2005. 9 http://www3.who.int/whosis/country/indicators.cfm?country=scg - accessed 31st March 2005 10 http://www.who.int/docstore/ncd/long_term_care/euro/yug.htm 11 Poverty Reduction Strategy Paper, Serbia; World Bank, 2004. 12 Poverty Reduction Strategy Paper, Montenegro; World Bank, 2003. 13 Mears Catherine, Health Programme Adviser, British Red Cross Society. Visit to Serbia and Montenegro; 16-21st March 2003. 14 Allaire Sandra. Report on the Initiation of a Home Care Programme in the Federal Republic of Yugoslavia, by the Yugoslav Red Cross Society; Canadian Red Cross Society May 2001. 15 Escribano Catalina Alcaraz, Project Officer on Elderly People, Activities and Services Department, Spanish Red Cross Society. Evaluation of the Home Care Programme for Elderly People Living in Central Serbia and Voivodina; 26th May - 7th June 2003. 16 IFRC. Report of the Home Care Programme; 2004. 17 Maxwell R J. Quality Assessment in Health. BMJ 1984;288:1470-2. 18 Maxwell J R. Dimensions of quality revisited: from thought to action. Quality in Health Care 1992;1:171-177. 19 http://www.sign.ac.uk/guidelines/fulltext/49/index.html - accessed 2 April 2005. 20 Annett H, Rifkin S B. Guideline for rapid participatory appraisals to assess community health needs; A Focus on Health Improvements for Low-Income Urban and Rural Areas; WHO/SHS/DHS/95.8. 21 http://www.timebanks.co.uk/ - accessed 3 April 2005.

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